The Joint Commission Medication Management Update for …

The Joint Commission Medication Management Update for

2018

Jeannell Mansur, R.Ph., Pharm.D., FASHP, FSMSO, CJCP Principal Consultant, Medication Management and Safety

Joint Commission Resources jmansur@ November 8, 2017

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Learning Objectives

? Identify at least one key issue found on survey relating to the top four challenging medication management standards.

? Identify 5 medication-related standards changes that will be surveyed as of January 1, 2018

? Describe expected actions relating to revised pain assessment and management standards, effective January 1, 2018

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Medication Management- Top Non-Compliant Standards/NPSGs for Hospitals (Jan-June, 2017)

Standard/NPSG

% Non-compliant

MM.04.01.01 Medication Orders MM.03.01.01 Storage and Security of Meds MM.05.01.01 Medication Order Review MM.05.01.07 Preparing medications NPSG.03.04.01 Labeling in OR/procedures MM.03.01.03 Emergency Medication NPSG.03.06.01 Reconciling Medications MM.09.01.01 Antimicrobial Stewardship MM.05.01.11 Safe Dispensing of Medications

49.28% 47.84% 14.94% 14.15 %

8.8% 8% 6.7% 4.2% 4.06%

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Medication Orders- MM.04.01.01 49.28%

Problematic EPs: ? EP 13: the hospital implements its policies for medication orders Failure to clarify unclear, illegible and incomplete orders- what's still on paper? Consistency in interpreting range orders Titration orders

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MM 04.01.01 Medication Orders Clear and Accurate

Range Orders

? Order must comply with organizational policy on required elements

? Dose range ? Interval range ? ? Both allowed

? There must be a process for interpreting how to carry out a range order

? Will there be consistent interpretation in all areas of the hospital?

? Pain scores are not required for pain orders

? Therapeutic duplication should be avoided

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MM 04.01.01 Medication Orders Clear and Accurate

Titration Orders

? Policy needs to delineated what must be included in the order: For example, starting dose, assessment parameters, and final endpoint. Consider max dose and/or when to call LIP .

? Example of an acceptable order :

? Start nitroglycerin infusion at 5 mcg/min IV. Titrate by 5 mcg/min every 5 minutes to keep SBP less than 160 mmHg and greater than 110 mm Hg. Max dose 200mcg/min. Contact responsible LIP if unable to titrate, SBP 90 mmHg, or continued chest pain or EKG changes.

? Titration policy with titration guidelines ? "... guidelines intended to be used with clinical judgement.."

? Problem prone on survey: Start Norepinephrine infusion titrate to a MAP greater than 65

Survey tip: Look at Oxytocin titration orders !

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Joint Commission Standards on Protocols, Standing Orders

and Order Sets for Medications What Hospitals Need to Know

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What is the Difference?

An order set is a list of individually selectable interventions or orders that the practitioner may choose from

? AMI, CHF, Pneumonia, Total Knee Replacement

A protocol requires the patient to meet certain clinical criteria, but there must be an order to initiate the protocol

? Heparin protocol

A standing order is an order that may be initiated without an initial order by the physicians or LIP by the nurse if the patient meets certain criteria. -ACLS , RRT, IV Start pre-op. ...

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